An elderly woman with shortness of breath and an ECG that helps understand it

 Written by Pendell Meyers, edits by Smith and GrauerOne of my fantastic residents brought me an ECG on shift and asked for my interpretation without any context:What do you think?I responded that it looks like chronic right ventricular hypertrophy. This is due to the QRS morphology and axis including incomplete RBBB pattern in V1, precordial R wave progression reversal, matching deep S waves in leftward leads I and aVL, very rightward limb lead axis including R wave in aVR.  See Ken Grauer ' s comments below where he points out that the tall P-wave in lead II is diagnostic of right atrial enlargement, which supports RVH as well.The patient was in her 80s with history of atrial flutter, congestive heart failure, ESRD on hemodialysis, who was brought by ambulance to the ED for 2-3 days of worsening dyspnea, nausea, vomiting, diarrhea, and missed dialysis due to symptoms. EMS found her in respiratory distress, hypotensive to 70/50 mm Hg, and hypoxemic to 87% on room air. No prior history of right heart dysfunction, and an echo from 4 years ago showed normal right heart function.A bedside echo was performed and showed severe right heart strain, severely dilated right atrium and ventricle, with very poor RV EF.CT angio of the chest showed no pulmonary embolism.She required vasopressors and respiratory support, and was admitted to the ICU.A formal echo the next day showed: mild concentric LV hypertrophyhyperdynamic LV function, EF 70%no segmental WMAsRight ventricle...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs